Their Bad Mother

I kinda thought that debates about the reality and severity of post-partum depression were settled well before Tom Cruise made an ass of himself prattling on about exercise and vitamins, but apparently not.

Time Magazine published an article last week that questions the seriousness of post-partum depression and questions the utility and good of the Mothers Act, a piece of legislation that would systematize support and services for women struggling with PPD across the US. Which, I suppose, might be explained by citing the need for dialogue and debate yadda yadda, but seriously: how is dialogue about PPD furthered by questioning its seriousness and by questioning – doubting – the women who struggle or have struggled with it (not to mention, getting the facts wrong)? We can’t have constructive discussion about PPD and its effects when such conversations proceed from assumptions that women exaggerate the seriousness of their experience or that much of PPD is simply ‘baby blues’ or that efforts to help women lead inevitably and problematically to pharmaceuticals, because such assumptions shame PPD-sufferers and mothers who have depended upon medication to get through what is one of the most difficult periods of their lives.

Doubting and shaming women who do struggle or have struggled with PPD serves no-one. Time should know better. Better than Tom Cruise, anyway.

Below, the text of an open letter to Time to which I, along with scores of other women who have personal and professional interests in discussions about PPD, was a signatory:

An Open Letter to the Editors of Time:

Time has done a great disservice to all mothers who are suffering and will suffer from postpartum depression (PPD).  In
an article called “The Melancholy of Motherhood” journalist Catherine
Elton writes a distorted story that no doubt has already begun to
confuse and stigmatize women with PPD.   

We cannot understand why Time
would choose to sensationalize what is a very serious medical issue for
hundreds of thousands of women in the United States each year, and to
create controversy around the MOTHERS Act, the one and only piece of
legislation that would help to systematize support and services that
are sorely lacking in so many places throughout our country.

There are several points in the article that concern us:

1.The MOTHERS Act is not “dividing psychologists” as Elton opines.  The
American Psychological Association, the American Psychiatric
Association and the National Association of Social Workers
wholeheartedly endorse the MOTHERS Act.    In fact, you neglect to mention that much of the medical community supports the bill.  It
has been publicly endorsed by the March of Dimes, the American College
of Obstetricians and Gynecologists, the American College of Nurse
Midwives, the National Healthy Mothers Healthy Babies Coalition, and
the Association of Women’s Health, Obstetric and Neonatal Nurses, among
many others.  You didn’t represent any of them in
your piece, all of which are highly regarded organizations which have a
long record of dedication to the health of both mothers and babies.

2. Elton calls screening controversial and infers it may not even work. Many
women will tell you that screening saved their lives, and others who
were not screened wish they had been so they could have received
treatment sooner.  In fact, Elton interviewed at least two such women but they were not represented in the article.  Screening for PPD is an effective way to identify women who may have it.   Both
the sensitivity (misses few sufferers) and specificity (some, but not
too many false positives) of the widely-used and validated Edinburgh
Postnatal Depression Scale, for instance, is very well-established.  We’d be happy to send you multiple, contemporary, highly-regarded studies that support this.    

3. Elton states that “… increased screening could lead to an increase in mothers being prescribed psychiatric medication unnecessarily.”  First, the MOTHERS Act does not require screening.  Second, none
of the screening tools for depression were designed to take the place
of evaluation by health care professionals, so it is manipulation to
suggest that screening alone will yield treatment of any kind or
specifically treatment via medication.  In a
study of large scale universal screening efforts of more than 1000
pregnant and postpartum women, screening for depression did not lead to
greater rates of treatment (Yonkers et al., Psychiatric Services, 2009).  This is because there are many barriers to treatment, regardless of a positive screen.  Additionally,
for those who are able and choose to be treated, many women elect
methods that don’t include medication (Pearlstein et al., Archives of Women’s Mental Health, 2006). 


4. Time should be more careful when discussing the causes of PPD.  We
were surprised to see such a well-regarded publication misrepresent the
results of a small research study that provided evidence to support the
idea that a subset of women are more susceptible to hormonal changes as
a trigger for depression, such as PPD, by prefacing the results with
the unsubstantiated statement that “pregnancy hormones … have little to
do with PPD in most cases.”  This study showed
that for those with a known history of depression, the hormonal changes
that occur following delivery may increase one’s risk for developing
symptoms during the postpartum period.  Yet Elton
attempts to use these results to support Michael O’Hara’s
overgeneralization that women without prior history of “lots of anxiety
and depressive symptoms” (what does this even mean objectively?!) “are
unlikely to have problems in the postpartum period – not even close to
likely.”  Reporting results out of context to support the opinions of a source is appalling. 


fact that women who have had depression or anxiety in the past are more
likely to experience PPD is nothing new.  This is only one of
many risk factors that have been identified.  Your article, however,
attempted to make a previous history of depression or anxiety the
single key to identifying PPD.  This will lead women who are ill but
who have never been clinically diagnosed or treated for a mental
illness to believe they must not have PPD.  Many women who suffer will
tell you it was the first time they were ever treated for a mental
illness and the first time they came to realize they may have suffered
from depression or anxiety in the past.  You also leave out women who
have no history of depression or anxiety but ended up with PPD for
other reasons.  Perhaps you were not aware, for instance, that diabetes
is a risk factor for PPD (Kozhimannil et al., JAMA, 2009), as
is thyroiditis.  Women who deliver multiples or have babies born with
serious health problems also have a higher risk of getting PPD.


5.  The language used in the article frustratingly minimizes the devastation that PPD can cause.  Such
phrases as “the melancholy of motherhood” and “still, there is no
denying that the postpartum period is a difficult one for many women”
almost brush PPD off as a blue funk or a trying transition time for new
moms.  This signifies a clear lack of
understanding about the seriousness of this illness that somewhere
between 10 and 20% of women around the world suffer.  PPD impacts a mother’s ability to function on a daily basis.  It is not a difficult period.  Elton asks, “Does
PPD screening identify cases of real depression or simply contribute to
the potentially dangerous medicalization of motherhood?”  It
is no more medicalizing motherhood to identify and treat PPD than it is
to identify and treat gestational diabetes, which is universally
screened for and occurs in only 3.5% of mothers.


As Time
reported in June, the National Academies fully endorses screening for
parental depression and believes it is crucial, while also emphasizing
that screening is not helpful unless there is effective follow up and
treatment tied to it.  Supporters of the MOTHERS Act share that belief.  Although effective treatment is available, fewer than half of cases of postpartum depression are recognized (Gjerdingen et al., Journal of the American Board of Family Medicine, 2007).  Even fewer of those women ever receive treatment of any kind.

are terribly sorry about the experience of the one mother quoted in
your article, which happens on rare occasions, but we believe that the
MOTHERS Act would actually go a long way to prevent what happened to
her.   What this bill actually funds is research, education and awareness.  If
these pieces are put in place, women, families and medical
professionals will be better educated to prevent false positives from
screening.  A well-trained and educated physician
will know to refer the patient on to a specialist who can inform her of
various treatment options and monitor her to ensure the treatment she
chooses is effective.   A
woman who has been made fully aware of the kind of services she should
receive and the risks and benefits of the treatments available to her
will be able to make the best choice for herself and her family.

focused on one potential but unlikely consequence of the MOTHERS Act
rather than the actual content of the bill and why it is so sorely
 We are deeply disappointed.


Concerned Women

(Full list of signatories can be found HERE.)

(Pass it on.)

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